When Quality Measures Put Patients with Spinal Cord Injury at Risk

With today’s focus on transparency in health care, quality measures play an increasingly important role in determining Medicare reimbursement. Among the core measures subject to a financial penalty from the Centers for Medicare and Medicaid (CMS) is an above-average rate of catheter-associated urinary tract infections (CAUTIs), which has prompted acute care hospitals around the country to enact policies to reduce the number of infections.

“Hospitals and other care facilities have lowered their CAUTI rates by paying close attention to whether patients actually need a Foley catheter and by removing them when they don’t,” says Matthew Davis, M.D., clinical director of the Spinal Cord Injury (SCI) Program at TIRR Memorial Hermann and a clinical professor of physical medicine and rehabilitation at the John P. and Kathrine G. McGovern Medical School. “But healthcare professionals outside the field of rehabilitation are often unaware that many SCI patients suffer from neurogenic bladder, which requires management either by indwelling catheters or by intermittent catheterization. Premature catheter removal combined with poorly implemented intermittent catheterization can have disastrous consequences for these patients.”

Dr. Davis has devoted considerable time during the past year to raising awareness of the potentially negative effects of the CAUTI quality measure on patients with spinal cord injury. In March 2014, he urged physical medicine and rehabilitation specialists across the nation to participate in an open discussion held by the National Quality Forum (NQF) soliciting feedback about the measure. When the general public was invited to phone in with comments, Dr. Davis was among those who called. After listening to what he said, NQF officials put him in touch with the authors of the guideline at the Centers for Disease Control and Prevention.

In September 2014, two nationally recognized experts joined Dr. Davis on a conference call with top-ranking CDC officials. They were Todd Linsenmeyer, M.D., director of urology at Kessler Institute for Rehabilitation in New Jersey, and Steven Kirschblum, M.D., director of the Spinal Cord Injury Program at Kessler, who is internationally known for his work on spinal cord injury and rehabilitation and, at the time, was president of the Academy of Spinal Cord Injury Professionals (ASCIP). After nearly two hours of discussion, the experts were unable to convince CDC officials to change their position.

“The CDC seems to want a high level of evidence proving that patients with SCI are being harmed on a large scale by the quality measure, which goes against our discipline’s clinical practice guidelines for this population,” Dr. Davis says.

In a first step toward gathering the requested evidence, he and physical medicine and rehabilitation resident Elham Cohen, M.D., prepared a series of case studies that they hope will lead to a system for monitoring and responding to the unintended consequences of the practice of removing catheters from patients with SCI. Three of the four patients reviewed in the series developed varying degrees of renal dysfunction, and one patient developed new-onset atrial fibrillation related to the increased cardiac demand caused by autonomic dysreflexia (AD), the sudden and dramatic rise in blood pressure that can occur in SCI patients with injury above the sixth thoracic vertebra.

Autonomic dysreflexia can cause systolic blood pressures to rise into the 200s, leading to headache, diaphoresis, encephalopathy, seizures, strokes and cardiac dysfunction. AD is most often caused by bladder distension and disturbance of the normal synergistic coordination between bladder contraction and external urethral sphincter muscle relaxation during voiding. Both of these conditions put patients at risk for the buildup of urine and renal failure.

“Over the past year, SCI specialists from respected academic centers across the country have seen an increased incidence of neurogenic bladder mismanagement,” Dr. Davis says. “They have persistently raised concerns that the current structure of the CAUTI measure fails to accurately count CAUTIs in these patients, may actually increase UTIs related to poorly managed neurogenic bladder and corrupts decision-making that has profound implications on quality of life -- all while placing these patients at risk for conditions far worse than UTI. Despite urging from the National Quality Forum, we’re unaware of any efforts to monitor or quantify any adverse impact of the quality measure on SCI patients. The problem is that this issue is off the radar screen in the acute care setting.”

As a result of his advocacy efforts on behalf of spinal cord injury patients, Dr. Davis has been asked to chair the Advocacy Committee of the American Spinal Cord Injury Association (ASIA). ASIA and the ASCIP recently collaborated on a letter to The Joint Commission urging the commission to pursue the issue. The Joint Commission has arranged a conference call to discuss the issue with representatives from ASIA, ASCIP and the United Spinal Association.

At the same time, Dr. Davis and his team are working on the design of a study, to be conducted in collaboration with other centers, that will investigate how often patients with SCI are put at risk by the measure. “It will be interesting to see the difference in treatment and outcomes at specialty spinal cord injury facilities and non-specialty centers,” he says. “We’d also like to compare practice patterns before and after the CAUTI measure went into effect. We won’t stop advocating for patients with SCI until we know they're safe.”